1. No category

April 2015
Billing Guidelines
Nursing Facility
• Admission / Start-of-Care date (FL12 of the
UB) is required. This date must be specific to
the episode of care.
• Occurrence Code 54 and the corresponding
last date of a physician follow-up visit are
required on all Intermediate Care Facility
(ICF) and Skilled Nursing Facility (SNF)
claims.
• Occurrence Code 55 and the corresponding
date of death are required on all claims
submitted with Discharge Status 20, 40, 41 or
42. This is in addition to Occurrence Code 54.
• A valid Attending Provider National Provider
Indicator (NPI) is required on all ICF and SNF
claims.
Home and Community Based Services (HCBS)
• Type of Bill is 089X.
• Admission / Start-of-Care date (FL12) is
required. This date must be specific to the
episode of care.
• Type of Admission (FL14) is required. This
code indicates the priority of this admission.
• Point of Origin for Admission or Visit (FL15)
is required.
• Occurrence Code 55 and the corresponding
Date of Death are required on all claims
submitted with Discharge Status 20, 40, 41 or
42.
• Attending Physician (FL76, 1 & 2) is required
on all HCBS claims as follows:
o Consumer Direction (CD): The
worker’s assigned CD number will be
submitted as the Attending Provider.
o
o
The ID must be within the range of
CD00001 – CD99999.
Attending Providers with an NPI: The
provider’s NPI will be submitted as
the Attending Provider. The NPI must
be valid and recognized by BlueCross
BlueShield of Tennessee.
Atypical Attending Providers without
an NPI: The provider’s 7-digit
Medicaid ID number will be
submitted as the Attending Provider.
The Medicaid ID number must be
valid and recognized by BlueCross.
Claims Explanation Codes
Please refer to the following information in the event
you see these denials on your Remittance Advice.
Please contact Customer Service should you have any
questions about claims processed with these, or any
other Explanation Codes.
W22: This denial EX Code is generated when the
revenue code submitted is not valid for the provider.
For example, if a level 2 provider files revenue code
0191 for level 1 services, the claim will deny W22. A
corrected claim must be submitted.
SHD/DUP: These denial EX codes are generated
when a duplicate claim is submitted. Please refer to
your remittance advices to avoid duplicate claim
submission. If a claim has been denied and you have
questions regarding the denial, please contact
Customer Service for assistance prior to resubmitting
the charges.
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
*Sandata is an independent company that does not provide BlueCare Tennessee branded products and services. Sandata is solely responsible for the
services they provide.
Timely Filing- Rejected Claims and
Corrected Claims
Rejected Claim Timely Filing
If you have filed a claim that BlueCare Tennessee
(BCT) rejects, you may wish to make corrections and
resubmit. Rejected claims must be resubmitted
within 120 days of the date of service or within 60
days from the date of the original BCT rejection
notice, whichever is later.
Corrected Claim Timely Filing
Timely filing for corrected bills is 120 days from the
remittance date of a claim. If there are multiple
submissions of a corrected bill, the first submission of
the corrected bill will be used for adjustment.
CHOICES Customer Service Menus
Our CHOICES customer service menus are changing
in an effort to streamline the process for our
Providers needing assistance with CHOICES
Members.
After selecting Option 6 from the Main Menu, the
following options will be offered:
• Press 1 for assistance with an authorization
related to the member’s Plan of Care
• Press 2 for assistance with a late or missed visit
• Press 3 to refer a member for the CHOICES
Program
• Press 4 for assistance with a claim or payment
question
Deficit Reduction Act-Fraud and Abuse
Overview
The Deficit Reduction Act (DRA) was passed by
Congress in 2005 and went into effect on Jan. 1, 2007.
The DRA impacted all federally funded healthcare
programs, including State health care programs such
as TennCare. As a result, the MCOs that manage
TennCare benefits made some changes to comply
with the new legislation.
One provision of the DRA was that it allowed the
State to rebalance long-term care support systems.
As a result, TennCare launched the CHOICES program
in 2010.
April 2015
BCT CHOICES providers play an important role to the
success of this program through servicing members,
but just as important filing accurate claims. This is
requirement from BCT CHOICES, and, also the
federal government.
A vital part of the DRA, is the False Claims Act. BCT
CHOICES providers are responsible for submitting
claims accurately, which includes every component
of the submission. The liability of submitting false
claims is a global responsibility of providers and their
entire organization. The following examples provide
critical examples of your responsibility to this law:
• Anyone who knowingly submits a false claim
for payment:
• Anyone who conspires to get a false claim
paid;
• Anyone who documents that a
product/service is delivered/rendered
without knowing for sure;
• Anyone who produces, uses, or causes use of
false documentation that leads to avoiding,
concealing, or reducing an obligation to pay
or transmit money/property to the
Government;
• Anyone who produces, uses, or causes use of
false documentation that leads to a
false/fraudulent claim being paid or
approved;
• Anyone who has possession of
property/money used or to be used by the
Government that has been concealed or
reduced from the amount that was to be
delivered;
• Anyone who buys or receives pledge of an
obligation or debt/property from a
government officer/employee or member of
the Armed Forces who cannot sell or pledge
the property for themselves because of their
position.
Whistle Blowers are Protected
Any employee who has knowledge of false claim
submission should report it. The law protects
employees from employer retaliation following a
report as long as the employee reasonably believes
he/she is reporting a violation of the law. As a result,
the employer cannot discharge, demote, suspend,
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
harass or in any manner discriminate against the
employee for making a good-faith report. If the
report meets the specific legal requirements, the
reporter could possibly be awarded 15-30% of the
total recovery.
If you suspect fraud, there are several options for
filing a report:
• Call BlueCross BlueShield of Tennessee’s
Fraud and Abuse Hotline at 1-888-343-4221
• Online with BlueCross BlueShield of
Tennessee at
http://www.bcbst.com/fraud/index.page;
• Call the Bureau of TennCare from anywhere
in Tennessee at 1-800-433-3982; or
• Log onto
http://www.tn.gov/tnoig/ReportTennCareFr
aud.shtml
BCT CHOICES is committed to empowering our
providers, providing you with the mandatory
required training for the DRA is our
responsibility. The Provider Network Managers will
ensure that all of the training material, including the
required Attestation Form, is reviewed during the
site visit.
Here are some important reminders:
• Training is required for all employees. It is
recommended that the training be
incorporated into new hire training to ensure
that all new employees are trained.
• Once all employees complete the DRA
training, the training sign-in sheet and the
Attestation Form (signed and dated) should
be faxed to (615) 386-8589 to the attention of
your assigned CHOICES Provider Network
Manager.
o West Grand Region
 Sherry Metts
(sherry_metts@bcbst.com )
 Ashley McDonald
(Ashley_McDonald@bcbst.co
m)
o Middle Grand Region
 Vincent Cardi
(Vincent_Cardi@bcbst.com )
 Jeffrey West
(Jeffrey_West@bcbst.com )
•
•
April 2015
East Grand Region
 Bianca Merrell
(Bianca_Merrell@bcbst.com )
 Jonathan Miller
(Jonathan_Miller@bcbst.com )
Training must be conducted every three years
for all employees. A new Attestation Form
and current training sign-in sheet is required.
For additional training materials or
assistance with employee training, please
contact your assigned CHOICES Provider
Network Manager.
o
Community Living Services
Community Living Supports (CLS) is a communitybased residential alternative service for seniors and
adults with disabilities that encompasses several
options for community residential independence
through community integration. The CLS service
ensures resident’s choice and rights and must adhere
to the new HCBS setting rule. Please review the
following description and FAQ’s that provide further
details for provider requirements. If you are a
qualified provider, and interested in contracting with
BCT, please email your organization’s information
to CHOICESProviderRelations@bcbst.com
CLS services are individualized based on the needs of
each resident and person-centered plan of care. The
services and support for each individual may include:
•
•
•
•
•
•
•
Selecting and moving into a home;
Locating a suitable house mate;
Acquiring and maintaining household
furnishings;
Acquiring, and retaining improved skills for
daily living activities or assistance with daily
needs such as bathing, dressing, personal
hygiene, grooming, transferring and mobility;
Building and maintaining personal
relationships with family and friends;
Gaining employment opportunities or
pursuing educational options;
Scheduling appropriate medical services;
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
•
•
•
•
Participating in the community to include
faith based and social events that are selected
by the member;
Becoming aware of and effectively using
transportation, the police, fire and emergency
services for help, and general community and
general public help assistance;
Meal planning;
Self- administering of medication, including
assistance with administering of medications
as permitted pursuant to TCA 68-1-904 and
TCA 71-5-1414;
These are just a few of the services that a qualified
CLS provider can effectively support the CHOICES
member transitioning to the community. Below are
some frequently asked questions that will also assist
you.
Does the Personal Support Services Agency
license cover CLS services?
No, you will need to be licensed as one of the
following:
• Mental Retardation Semi-Independent Living
Services licensed provider by DIDDS for:
o CLS1
o CLS2
o CLS-FM1
o CLS-FM2
• Mental Retardation Supported Living and/or
residential habilitation facility provider by
DIDDS for :
o CLS3
o CLS-FM3
Who develops the plan of care?
The CHOICES care coordinators will be responsible
for developing the plan of care. The plan of care will
include relevant information of the members’
services, natural supports, back-up plans, disaster
planning, summary of member needs, and member
qualification. Each MCO may have different formats
but the plans of care will contain the same
information.
April 2015
How will medications be administered?
CHOICES members will be allowed to use selfdirection for medication administration if
determined appropriate. A verbal order will be
obtained from the member’s Primary Care Provider
(PCP) and included on the plan of care, allowing a
paid worker to assist in this health care task. This is
limited to the administration of oral, topical and
inhaled medications.
When will CLS services become a contracted
event?
Currently, BCT CHOICES will enter into single case
agreements for qualified providers that meet the CLS
standard requirements. For reimbursement and
details regarding the process to secure a single case
agreement, please contact BCT CHOICES
at CHOICESProviderRelations@bcbst.com.
CHOICES Nursing Facility Provider Update
A rather large component of having nursing facility
claims paid correctly and on time encompasses a
Nursing Facility (NF) to utilize the accurate provider
ID numbers. For nursing facilities, please remember
that as a CHOICES provider you are given a two
different provider ID numbers for Skilled Nursing
(SN) and Long Term Care (LTC). To assist with the
different provider numbers assigned for BCT
CHOICES, we have given your facility one provider
number that is for LTC (Level 1) and a separate
provider ID number that is given for the SN (Level
2). If questions arise about your provider ID
numbers, please contact the assigned Provider
Network Manager to your facility to retrieve your
two different provider ID numbers.
Please review the updates again for requesting and
approving Enhanced Respiratory Care Services for all
CHOICES members to meet our contractual
agreement with the Bureau of TennCare. The
processes may affect claims processing if they are not
adhered to.
When requesting chronic ventilator or ventilator
weaning authorizations, the nursing facility must
provide information to BCT and adhere to the
following:
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
1.
2.
3.
4.
5.
6.
7.
NF will send a signed attestation which
attests to the licensure and availability of
an enhanced respiratory care bed in the
facility. This form will be provided by
BCT and is to be returned within 48 hours
via Fax: 1-855-273-5838
For requests of chronic ventilator or
frequent tracheal suctioning for CHOICES
members, there must be a current and
approved Pre-Admission Evaluation
(PAE) in TennCare Pre-Admission
Evaluation System (TPAES) with the
approved services and dates of approval.
For requests of ventilator weaning, NF
must complete the Enhanced Respiratory
Care Ventilator Weaning Request Form
provided by BCT. This must be returned
via Fax: (423) 535-7790
For initial and continued authorizations,
the NF must send BCT supporting
documentation every 30 days with an
attestation.
 Signed physician orders
 Current Respiratory Log for
30 days
 History and Physical
 Nursing Progress Notes
If the review of documentation by BCT
indicates a change in the utilization of
services for chronic ventilator services,
then BCT CHOICES will request the NF to
complete Enhanced Respiratory Care
Ventilator Weaning Request Form to be
faxed to BCT Transition of Care via
Fax: (423) 535-7790
BCT will provide letters for approval or
denial of requests.
Required forms to be utilized beginning
April 1, 2015.
April 2015
Critical Incident Reporting Mandatory
Timeframes
The following are critical incident mandatory
reporting timeframes for BCT CHOICES HCBS
services:
• A 24-hour verbal report is required to BCT at
1-888-747-8955 followed up by a written
report within 48 hours of initial discovery.
• Immediate reporting to Adult Protective
Services (APS) for abuse, neglect and financial
exploitation* at 1-888-277-8366, or by fax to
1-866-294-3961.
• Immediate reporting to BCT for physical or
sexual abuse or unexpected death at
1-888-747-8955. This phone number rolls to
Nurseline after hours and on weekends.
• Immediate removal of the worker from
interaction with ALL TennCare members for
the duration of the investigation.
• A 20-day written follow-up report via email
at CHOICES_Quality_GM@bcbst.com
or CHOICESQuality@bcbst.com, or by fax at
(615) 565-1923 or (855) 292-3715.
*Financial exploitation includes any funds for
which a government source cannot be ruled out.
Note: It is a requirement that your organization
has a process in place to provide and document
initial and ongoing education to your employees
who will provide services to CHOICES members.
This includes critical incident reporting. Your
policies and procedures must be adequate and
inclusive all details surrounding this process.
During your site visits, the Provider Network
Manager will review each policy and procedure to
determine if the details documented support the
contractual agreement noted in C.R.A 2.11.3
Implementation Phase II
As a BCT Provider you are probably aware of the
changes that have been going on since
Jan. 1, 2015. BCT started receiving transferred
members in the Middle Grand Region from the other
two participating MCO’s while at the same time
having some of our members transfer to a different
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
MCO in the East Grand and West Grand Regions. This
was Phase I and the members have already been
transferred or opted back to their previous
MCO. Phase II is already in motion behind the scenes
and the member reassignment date will be
April 1, 2015. The member will have the option to
opt out of their new provider up to May 15, 2015.
If you have a member who has been notified they will
be reassigned there are things you should look
for. First, please keep an eye out for an authorization
from BCT CHOICES. The authorizations should be the
same services you are providing pre-transfer, but if
there are any discrepancies please call
1-800-468-9736 or email the specific information
to CHOICES_GM@bcbst.com..
Second, if you receive a faxed authorization, but the
services are either not showing in the Electronic Visit
Verification (EVV)/Sandata system please call the
support center at 1-800-782-2433 or email the
specific issue to ProviderAuthIssues@bcbst.com.. It
is highly recommended to copy your Provider
Network Manager on all correspondence so that they
are aware of any issues and can assist you in the
resolution.
Last but not least, please insure that you have all of
the following that apply:
• BCT CHOICES Database in EVV/Sandata
(Attendant Care, Personal Care, In Home
Respite, Home Delivered Meals, and Adult
Day Care Providers). If you require
further training or do not have this
access, please contact your BCT CHOICES
Provider Network Manager for the next
steps.
• BlueAccess Log In and “Shared Secret”
(ALL PROVIDER TYPES). Assisted Care
Living Facilities, Assistive Technology,
Critical Adult Care Homes, Minor Home
Modifications, Nursing Facilities, Personal
Emergency Response Systems, and Pest
Control providers have the option to
submit claims via this web portal as well
if they choose to not use a third party
April 2015
vendor. If you have more than one
provider ID (such as a Nursing Facility
that offers Skilled Nursing and Long Term
Care) please insure your numbers are
linked. If you have any questions
regarding BlueAccess, please call
(423) 535-5717 option 2.
Thank you again for being a valued provider for BCT
CHOICES and if you have any questions, please call
provider services or your Provider Network
Manager.
HCBS Settings Final Rule
Intent
For the first time, HCBS Settings Final Rule sets
federal standards to ensure that Medicaid-funded
HCBS are provided in settings that are not
institutional in nature. These standards apply to
residential and non-residential (for example, day
program) services and settings. The rules focus on
the experience of each person receiving services and
supports—Are they living the life they want?
Standards that Apply to ALL HCBS Settings
• Integration with community
o Is the setting a part of the community
so that people can access and use
their community?
o CMS expects to see that people in
Medicaid HCBS programs have the
same chances as everyone else does
to be in and use their communities –
to find jobs, go to activities in their
community, use the library, get a
haircut when and where they want,
etc.
 Do people in the setting have
access to public
transportation?
 Can people work if they want
to?
• Choice
o Is the setting selected by the
individual from among setting
options, including non-disability
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
o
o
•
•
specific settings and an option for a
private unit in a residential setting?
This means that the person must be
able to choose where they live, not
just be ‘assigned’ to live in a home or
setting meant only for people with
disabilities.
Also, this does not mean everyone
gets a private unit. This means that if
someone wants AND can afford to live
alone, they must be given options of
settings that include a private unit.
Rights
o The setting must ensure the person
has rights of privacy and dignity, and
is treated with respect.
o Are schedules for therapy or medical
appointments posted in public areas
where everyone can see them?
o Are people called by their preferred
name or are they called “hon” or
“sweetie”?
o The setting must ensure the person
will have freedom from coercion and
restraint (will not be forced to do
things they do not want to do).
Independence
o The setting must support the person
to maximum their ability to be
independent in making life choices,
this includes things like:
 What I do each day
 Where I live and how it is
decorated
 Who I hang out with
o The person must be supported to
choose the services they need and
who provides them
HCBS Provider Self-Assessment
The following provider types are required to
complete and submit a Self- Assessment and
Transition Plan, as necessary, demonstrating their
agency’s compliance:
Residential Providers:
• Assisted Care Living Facilities (ACLF)
•
•
April 2015
Adult Care Homes
Residential Habilitation (includes Medical
Residential and Community Living Supports )
• Supported Living (includes Medical
Residential and Community Living Supports)
• Family Model Residential (includes
Community Living Supports)
Non- Residential Providers:
• Facility Based Day
• Community Based Day
• In-home Day
• Supported Employment
• Adult Day Facility
Self-Assessment
Each provider will receive a link to the selfassessment tool. The assessment questions are in
Yes/No format. Each question answered ‘Yes’ should
have corresponding documentation to serve as
evidence of compliance. Each question answered ‘No’
should be included in the Transition Plan.
Providers will use a ‘Crosswalk’ in order to identify
which documents are associated with each question
on the Provider Assessment in Wufoo.
State Transition Plan
HCBS providers will complete their self-assessment
and provide their reviewing MCO with evidence that
they are following the new rules, or what they will
change to begin following the new rules.
MCOs will review the evidence, ask for more proof if
needed, or a plan if changes are needed to comply
with the new rule. If a provider is unwilling or unable
to comply with the new rules, they can no longer
provide HCBS - People served will transition to new
providers
http://www.tn.gov/tenncare/forms/NewRulePresen
tationforConsumersFamilies.pdf
Electronic Visits Verification (EVV)
Updates
Middle Tennessee Implementation Provider
Reminders (Participating and Non-Participating)
What changes took place?
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
TennCare transitioned from two MCOs in each Grand
Region of the state to three MCOs Statewide. Since
Jan. 1, 2009, United Healthcare and BCT have
operated in East and West Tennessee and
UnitedHealth Care and Amerigroup have operated in
Middle Tennessee.
Jan. 1, 2015, UnitedHealth Care, BCT and Amerigroup
began operating statewide. This offers more options
to our CHOICES members. Since three MCOs are
available to members, remember some members
transitioned to a new MCO to ensure even
distribution of enrollment.
Date Reminders
Feb. 13, 2015:
Notices were sent to Phase 2 transitioning members
informing them of their new MCO assignments.
Feb. 14, 2015:
Phase 2 members were sent a notice reminding them
of this date to request to stay with their current MCO.
Members also received information on how to
request to stay, which was included with their notice.
Members continue to be enrolled in their current
MCO until Mar. 31, 2015. Members were also advised
that they can only transition to their new MCO or
request to stay with their current MCO; they cannot
request to move to another MCO. They will be able to
choose any MCO during their annual open enrollment
period.
April 1, 2015:
Members who were sent notices and did not request
to stay with their current MCO transitioned to their
new MCO. This could mean they will have to see new
health care providers if you are not contracted with
their MCO. If you are non-participating providers, we
request that you support the transition and continue
services as outlined on the current Plan of Care. If
you have questions,
contact ChoicesProviderRelations@bcbst.com.
May 15, 2015:
Members who transitioned to a new MCO have until
this date to request to change back to their previous
MCO. There is information on how to request to
change back to their previous MCO included with
April 2015
their notice. This is not a hard deadline. Members can
still opt out after this reassignment date.
Continuity of Care for CHOICES Members
Starting April 1, 2015, CHOICES members moved to
their NEW MCO. Until at least April 30, 2015,
members will keep getting the same long-term
services and supports they had. And, members can
get them from the same nursing home or home care
providers that they had before the reassignments.
Providers, if members selected to continue with their
same provider of services, please continue to provide
these services (participating and non-participating
providers).
What happens after April 30, 2015? If you are
currently not contracted with BCT and wish to do so,
contact the Provider Relations Team at
ChoicesProviderRelations@bcbst.com.
EVV Reminders
If you are required to use the EVV system for your
staff checking in and out and submission of claims
(Adult Day Care, Attendant Care, Companion Care,
Home Delivered Meals, In-Home Respite, Personal
Care), see below:
•
Please remember to review Imported Members
(these are your newly assigned members) noted with
a yellow icon as CM Middle.
•
Make these members active and begin creating
templates for your preset schedules.
•
Please remember to check the member's
eligibility via the client general screen to ensure the
member is still eligible to receive services with BCT
as the members eligibility could change due to the
opt out period.
•
If you have issues with your authorizations as it
relates to the transition of members you currently
services, please notify BCT
via ProviderAuthIssues_gm@bcbst.com. Be sure to
include the member's first and last name, member
identification number, authorizations number, and
specific details related to your authorization issue.
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association
Provider Monthly Education
April 2015
BCT CHOICES Provider Relations will host Monthly
Educational Provider Webinars and Quarterly
Provider Summit Meetings. For your convenience the
Webinars will be facilitated as WebEx Presentations
and Provider Summit meetings will be hosted
throughout the state. Notification of these important
educational opportunities will be submitted to each
BCT CHOICES Provider and via email and/or fax
blasts. Please be on the lookout for these
correspondences.
South West and South East lower Middle Region:
Jeffery West
Jeffrey_West@bcbst.com
(615) 565-1937
Webinar
April 28, 2015
North East and South East West Region:
Ashley McDonald
Ashley_McDonald@bcbst.com
(901) 544-2136
To ensure we have the most up to date provider
contact information, please contacted to your
assigned Provider Network Manager.
May 28, 2015
(subject to
change)
July 28, 2015
Aug. 27, 2015
Sept. 24, 2015
Oct. 27, 2015
Subject
Credentialing, Re-credentialing
and provider site visits
Nursing Facilities (Enhanced
Respiratory Care, Claims
Submissions)
HCBS New Setting Rule
CHOICES Program (including CLS)
To be determined (TBD)
TBD
Quarterly Provider
Summit Meetings
June 25, 2015
Location
Topics
Memphis, TN
Nov. 17, 2015
TBD
CHOICES
Program
(including
New Setting
Rule, and
CLS)
TBD
North West and North East Middle Region
Vincent Cardi
Vincent_Cardi@bcbst.com
(615) 565-1907
North West and South West Region
Sherry Metts
Sherry_Metts@bcbst.com
(901) 544-2459
Contact Information
BCT Provider Service: 1-800-468-9736
TennCareSelect: 1-800-276-1978
Care Coordination: 1-888-747-8955
NurseLine: 1-800-262-2873
Nursing Facility Hotline: 1-866-502-0056
Sandata Client Relations (EVV):
1-877-526-0516
Provider Network Managers
South Eastern Region:
Bianca Merrell
Bianca_Merrell@bcbst.com
(423) 535-5900
East and North Eastern Region:
Jonathan Miller
Jonathan_Miller@bcbst.com
(423) 854-6001
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association